3/21/2010 @ 10:50PM

Health Reform's Winners And Losers

WASHINGTON — The biggest health care overhaul in nearly half a century is about to become reality.

The House of Representatives passed health care reform legislation Sunday night by a vote of 219-212, effectively ending a year’s worth of political horse trading and lobbying. The bill now goes to President Barack Obama for his certain approval. After the vote, House Democrats broke out into a chorus of “Yes we can, yes we can,” the signature slogan of Obama’s presidential campaign. But the real workings of reform are only now beginning as industry stakeholders, the public and the courts prepare to deal with the fine print of how the legislation will be implemented.

The overhaul gives an additional 32 million Americans access to basic health insurance by 2019, according to the Congressional Budget Office. The biggest change in the American health system since Medicare was enacted in 1965, the reforms are expected to cost $938 billion during the next decade. It is going to be paid for by cuts in Medicare, new taxes on investment income and fees on various industry participants–which certainly will be passed along to the general public. But while government subsidies for people who cannot afford insurance and insurance exchanges to help people get insurance won’t be operational before 2014, the increased costs will begin next year.

Big changes are coming for small business. Companies with more than 200 workers will be required to automatically enroll their employees in whatever insurance plan they offer. Companies with at least 50 workers are subject to fines if their workers end up receiving government subsidized coverage. The bill also contains tax breaks for small firms that provide employees with health insurance.

The legislation may be going to Obama for signing, but the action isn’t over in Congress. Following the passage of the bill, the House passed a so-called “reconciliation bill” to make adjustments to the Senate-defined package. However, the Senate has yet to take up the reconciliation bill. Senate Democrats have assured their counterparts in the House that they have enough votes to pass the reconciliation bill next week. It will only need a simple majority vote. The president would then sign the alterations into law. Assuming the reconciliation process is completed, here’s a look at which groups are the biggest winners and losers in health reform:

WINNERS

The Uninsured

According to the Congressional Budget Office, 94% of all non-elderly Americans will have access to health insurance by 2016, vs. 83% now. Health insurers won’t be able to deny coverage based on pre-existing conditions. People who elect not to get insurance will have to pay a penalty of $695 per year or 2.5% of income (phased in before 2016). But state-based exchanges will be set up to make shopping for an insurance plan easier. Generous subsidies will be available to families that make up to $88,000 in household income.

Private Insurers

America’s Health Insurance Plans, an industry group for private insurers, has complained that health care reform leaves 23 million Americans uninsured, imposes drastic cuts in Medicare Advantage and levies a $70 billion tax hike (over 10 years) on the industry. While HMOs whine a lot, they actually came out OK. Their biggest nightmare was long ago removed from the legislation: a government-run plan to compete with private companies. Better yet, health insurers get 32 million new taxpayer-subsidized customers. In essence, it’s a big Cash for Clunkers program for HMOs.

Among the HMOs, the biggest winners are
Cigna
,
Aetna
and UnitedHealthcare
because they are concentrated in big employer markets that will be largely unaffected by the bill. The bill is more likely to have a negative impact on
WellPoint
and
Humana
. WellPoint could lose shelf space in the individual market it now dominates in many states. Humana has a big Medicare Advantage business and will get hammered by the reimbursement cuts.

Drug and Biotech Companies

Drug companies like
Merck
,
Pfizer
and
Amgen
are among the biggest industry winners in the legislation. They suddenly will have tens of millions more insured customers who can afford their expensive medicines. The pharmaceutical industry’s trade group was a big supporter of the legislation, and any threats to the industry were stripped out early or never included. There’s no real plan for comparing treatments to one another, one approach that could lower costs, or for giving the government power to bargain for lower prices. The bill also gives drug makers extra layers of monopoly protection for protein-based biotech drugs, one of the industry’s hottest areas.

In recent years drug makers have switched from selling mass-market pills to high-priced specialty medicines for cancer and nasty diseases. New drugs for rare diseases frequently cost $100,000 or more. In these markets, the key is not avoiding pricing pressure from HMOs, but making sure as many people as possible are covered under some kind of health plan. The legislation means that many more people will be able to pay full freight.

Seniors Who Need Prescription Drugs

The bill closes the “donut hole” in Medicare Part D plans. AARP made sure this was in the bill. Additionally, for adults who aren’t quite 65, new regulations will prevent insurance companies from denying coverage because of age.

Trial Lawyers/Litigious Patients

The bill has nothing in it that might lead to medical tort reform. By some estimates, billions of dollars in unnecessary lab tests and imaging studies are done every year by doctors who fear lawsuits. Moreover, expected challenges to health care reform, such as efforts in Virginia and Idaho to prevent the U.S. government from forcing citizens to obtain health insurance, could be a boon for lawyers.

Medicaid Recipients

The bill expands eligibility for Medicaid as part of its coverage mechanism. It also increases Medicaid reimbursements, which will make it easier for patients on Medicaid to find doctors who take their insurance.

The Senate bill’s excise tax on high-cost insurance plans, which unions objected to during the legislative process was gutted. Now it kicks in at a higher cost level than originally conceived ($27,500 vs. $23,000 for family coverage) and in 2018. This means there’s plenty of time for maneuvering to make sure it never takes effect.

LOSERS

The Insured

If you already have good insurance, the bill will probably drive up your premiums. This is especially true if you buy your own insurance but don’t qualify for any of the new subsidies. A family in California that buys its own insurance but makes more than the $88,000 cut-off for subsidies will be hit with a double-digit increase in the cost of coverage, above and beyond inflation.

But even if you get your insurance at work you’ll have to indirectly cover the new taxes on medical providers. Also, it’s likely that those who have private insurance will face higher rates from hospitals, doctors and medical testing labs as providers try to make up for increased numbers of low-paying Medicaid customers. There are too many factors here to make detailed predictions, but if you have insurance, get ready to open your wallet.

Doctors

Doctors wanted two things from health reform: tort reform and a fix to the Medicare payment formula that automatically cuts reimbursements each year. They got neither. The American Medical Association consistently supported the legislation even though it never got what it wanted. Doctors are said to be politically naive, and the AMA was Exhibit A this year.

One reason that the so-called “doc fix” isn’t in the current legislation is that it would make the bill cost a lot more. In April Medicare payment rates for doctors are scheduled to fall by 21%. Adding the doc fix to the bill would have put Uncle Sam nearly $60 billion further into the red, instead of reducing the deficit by $143 billion by 2019, as the CBO estimates the current legislation will do. Physicians will have to hope that Congress makes a separate adjustment to Medicare payments later in the year. But few politicians are likely to take on such an expensive task during an election year.

The Wealthy

To help pay for the bill, there’s a 0.9% increase in Medicare payroll taxes for people who earn more than $200,000 annually ($250,000 for couples). In addition, those earners would be subject to a new tax of 3.8% on investment income like dividends and capital gains beginning in 2013. The House’s 5.4% “millionaire’s tax” got scrapped as a result of the Senate bill replacing the House bill as the template for the final legislation.

According to tax experts at Deloitte, single filers earning $350,000 annually would see their taxes rise by $2,700 under the tax hikes imposed by health care reform and proposals in the president’s most recent budget. Singles earning $5 million annually would have an additional $285,700 tax burden. Couples with annual income of $5 million would be subject to a $287,100 tax increase.

Banks

Banks are affected adversely by health care reform, believe it or not. The reconciliation bill includes an amendment that scraps government funding or guarantees for the Federal Family Education Loan Program after June 30 of this year. FFEL loans, offered by private lenders, are subsidized and guaranteed by Uncle Sam. The move places greater emphasis on the government’s Direct Loan program, where student aid is offered through the Department of Education.

Health care reform has been the top item on the political agenda for the past year. Heres a look back at some of the highlights.